Healthcare Provider Details

I. General information

NPI: 1619073178
Provider Name (Legal Business Name): JOETTA M KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOETTA M RUEBUSH RD, LD

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WASHINGTON RD
WEST POINT NY
10996-1109
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 315-774-8200
  • Fax:
Mailing address:
  • Phone: 210-539-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT07527
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: